MEDICARE: LAWRENCE HALL YOUTH SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251B00000X	Case Management Agency	012231-09, 012232-19	IL
2	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	012231-09, 012232-19	IL

General Provider Information

NPI Number	:	1588623466
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAWRENCE HALL YOUTH SERVICES

Provider Business Mailing Address
First Line	:	2737 W PETERSON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60659-3927
Country	:	US
Telephone Number	:	773-728-2807
Fax Number	:	773-728-0751

Provider Business Practice Location Address
First Line	:	4833 N FRANCISCO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-3640
Country	:	US
Telephone Number	:	773-769-3500
Fax Number	:	773-769-6467

Authorized Official
Title or Position	:	CHIEF FINANCIAL OFFICER
Name	:	MR. MARK D. NUFER
Credential	:
Telephone Number	:	773-728-2807

Provider Enumeration Date	:	03/21/2006
Last Update Date	:	05/17/2012

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